Claim Form for Non Ward Reimbursement
Service Agency Maintaining an Interim Program School
or an Approved or Accredited School
CLAIM FOR NON WARD EDUCATIONAL SERVICE REIMBURSEMENT
Use this form to claim reimbursement for non-wards who (for other than educational reasons) reside in residential settings maintaining an approved interim program or approved or accredited school. Reimbursement for students who are wards or who are residing in residential settings for educational purposes are claimed through other means. Reimbursement claims for non-wards residing in residential settings maintaining an interim program or an approved or accredited school must be submitted on the “Claim for Non Ward Educational Service Reimbursement” form. Claims submitted by the 15th of the month will be processed that month. Claims submitted after the 15th of the month will be processed the following month.
Forms may be filled out electronically, but a copy must to be mailed to:
Nebraska Department of Education
Office of Special Education
301 Centennial Mall South P.O. Box 94987
Lincoln, NE 68509-4987
Instruction for Completing the Form:
Service Agency Name – Complete Name of the Service Agency as indicated on Service Agency Provisional Approval Letter
Service Agency Code – The number assigned to the Service Agency by NDE as indicated on Service Agency Provisional Approval Letter
Service Agency Address – Location of Service Agency in Nebraska including street address and PO Box, City, and zip code
Service Agency Interim Program School name or Approved or Accredited School name and number – Complete name of interim program school as appears on Rule 18 approval form or the name and assigned number of approved or accredited school
Contact Person – Service Agency Person to contact in case of questions or needed clarification
Email Address – Email address of the Service Agency contact person
Phone Number – Phone number of the Service Agency contact person
Service Code – Service code for the service provided to the non-ward. The service agency may only claim reimbursement for services for which they have an approved rate
Student Name – Last name, first name and middle initial
Residential Setting – Name of the location in which the child resides
NDE Student ID – 10 digit number assigned to the student and used to submit data to NDE (NSSRS)
Resident District – Include the student’s public school district of residence and the district number
Verified Disability – As per Rule 51, Verifying disability categories are Autism, Behavioral Disorder, Deaf- Blindness, Developmental Delay, Hearing Impairment, Mental Handicap, Multiple Impairments, Orthopedic Impairment, Other Health Impairment, Specific Learning Disability, Speech-Language Impairment, Traumatic Brain Injury or Visual Impairment.
Ward – Means a child who, as determined by the State where the child resides, is a foster child, a ward of the State, or is in the custody if a public child welfare agency.
Start Date – The date on which the student began receiving services for the current claim. Include the day, month and year (mm/dd/yy)
End Date – The date on which the student stopped receiving services for the current claim. Include the day, month and year (mm/dd/yy)
Number of Days – The total number of days the student attended and received service for the current claim
NDE Approved Daily Rate – Rate for educational services approved by NDE
Amount Total – Total amount of the current claim. The amount is determined by multiplying the number of days the student attended and received services by the NDE approved rate for the services provided. A service agency can only claim reimbursement for the services for which they have a NDE approved rate
Select Only One:
Sped Service – Services provided to a non-ward with a verified disability pursuant to the student’s IEP
Support Services – Services provided to a non-ward who does not have a verified disability but who demonstrates a need for specially designed assistance by residing in a residential setting described in 79-215(10) (a).
Certifications – An authorized official of the service agency must certify that the claim is true and accurate, is only for the services provided, does not include costs for residential services and that supporting documentation is maintained by the agency. The service agency official must also certify that the student is not a ward of the State, is placed in the residential setting for other then educational purposes and is unable for health or safety reason to attend a public school.
Signature/ Date – Signature of the Authorized Service Agency Official and date signed
Name/Position – Name and Title of the Authorized Service Agency Official